West Anaheim Medical Center D/P SNF

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services for the use of the GT were provided for four of six final sampled residents (Residents 3, 4, 8, and 12) reviewed for tube feedings. * The facility failed to ensure Resident 3 and 4's HOB were elevated above 35 degrees while the enteral feeding formula was infusing, as per the physician's orders. * The facility failed to ensure Resident 12's enteral feeding formula was labeled with the correct feeding rate. * The facility failed to ensure LVN 1 mixed the crushed medication with water prior to the administration of the medication via GT for Resident 8. These failures posed the risk of complications related to use of the GT for Residents 3, 4, 8, and 12.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care services for four of seven final sampled residents (Residents 2, 3, 12, and 15) reviewed for respiratory care. * The facility failed to ensure Yankauer suction tubing was changed as per the physician order for Resident 2. * The facility failed to ensure the Yankauer suction tips were changed as per the physician's order and care plan for Residents 3 and 12. * The facility failed to ensure the manufacturer's recommendation for cleaning and disinfecting of the ventilator machines was followed for Resident 15. These failures had the potential to affect the respiratory health and well-being of the residents in the facility.

Inspectors wroteBased on observation and interview, the facility failed to store the drugs and biologicals in a safe manner for one of two medication carts (Medication Cart A) and one of 12 final sampled residents (Resident 3). * The facility failed to discard the bottle of sterile water at Resident 3's bedside. * Two sterile alginate wound dressings (highly absorbent wound dressing) with antimicrobial silver (potent antimicrobial agent), and one sterile Puracol (Collagen) Plus wound dressing were observed opened and stored inside Medication Cart A. These failures had a potential to negatively impact residents' physiological well-being by exposing the residents to contaminated dressings and irrigation fluids.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure a blender container was dried thoroughly. * The facility failed to ensure the food preparation equipment was properly cleaned. * The facility failed to ensure proper labeling and dating of opened food items in the refrigerator. * The facility failed to ensure a dry food was stored properly. * The facility failed to ensure the proper storage of the employees' personal food in the kitchen was observed by the staff. * The facility failed to ensure the use of hair restraints was implemented by the facility staff who entered the kitchen. * The facility failed to ensure the cooking utensils were in good condition. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the staff provided care and services to promote dignity and respect for one of 12 final sampled residents (Resident 13). * Resident 13's family member preferred Resident 13 not to be covered or to wear a shirt. The facility failed to ensure Resident 13's curtain was pulled to provide Resident 13 with dignity. These failures had the potential to negatively impact the resident's self-worth and well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop a comprehensive plan of care to reflect the individual care needs for one of five final sampled residents (Residents 16) reviewed for unnecessary medication. * The facility failed to develop a care plan for Resident 16's use of Xarelto (anticoagulant medication). This failure posed the risk of not providing appropriate, consistent, and individualized care to the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P, the facility failed to ensure the comprehensive plans of care were revised to reflect the residents' current care needs and interventions for three of 12 final sampled residents (Residents 3, 4, and 15) reviewed for care plans. * The facility failed to ensure Resident 3 and 4's care plans were revised to reflect the physician's order for aspiration precautions, to elevate the head of the bed to 35 degrees at all times. * The facility failed to ensure Resident 15's care plan for the use of the mechanical ventilator machine was revised to include the cleaning of the machine. These failures posed the risk of not providing the residents with individualized and person-centered care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide an individualized and ongoing activity program to meet the needs and interests for one of 12 final sampled residents (Resident 5). * The facility failed to provide documentation Resident 5 had received meaningful activities as per the care plan. This failure had the potential to affect the resident's psychosocial well-being. Findings; Review of the facility P&P titled Activity Plan dated 6/2025 showed an activity plan will be developed and implemented for each resident and shall be integrated with the individual interdisciplinary resident care plan . The purpose of the activity plan is to assist the activity personnel and the rest of the unit staff in providing for each resident those activities that will provide the highest quality of life that is possible for the resident. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the quality care and services were provided for one of 12 final sampled residents (Resident 11). * The facility failed to ensure Resident 11's POLST was complete and accurate, and discussed in the facility IDT meeting, when Resident 11 did not have a responsible party. This failure had the potential to result in care being provided that did not reflect the resident's treatment preferences, leading to unwanted interventions, delays in appropriate care, and compromising the resident's overall health and well being.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of three final sampled residents (Resident 11) reviewed for nutritional status received the appropriate services needed to maintain acceptable parameters of the nutritional status. * The facility failed to ensure the physician was notified when Resident 11 had excessive weight changes of more than 5 (five) pounds in a week, and 20 pounds in a month. This failure had the potential to result in the lack of effectiveness of the nutritional interventions and increased the potential for further weight loss and/or nutritional decline.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services to maintain the intravenous (IV) accesses for one of 12 final sampled residents (Resident 13) reviewed for IV care. * The facility failed to ensure a physician's orders were obtained for the IV fluid and peripheral IV access site rotation every 72 hours and as needed. This failure had the potential to delay the identification of intravenous complication of the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate administration of the medications when two of four licensed nurses were observed to have made errors. * LVN 5 failed to follow the administration instructions to dissolve the GlycoLax (laxative) for Resident 21. * During the medication administration observation, LVN 6 failed to administer the Pro-Stat (liquid protein supplement) medication to Resident 6. These failures had the potential to negatively affect the residents' health conditions and posed the risk of possible complications or delay in interventions.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to implement their infection control program in accordance with the facility's P&P. * The facility failed to ensure LVN 1 donned the appropriate PPE during the medication administration observation for Resident 8 via the GT; additionally, LVN 1 failed to disinfect the stethoscope after use and prior to exiting Resident 8's room. * The facility failed to ensure RN 2 removed the gloves, performed hand-hygiene, and donned new gloves in between the administration of eye ointment medication for both eyes. These failures had the potential for the spread of infection to the residents, staff, and visitors in the facility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services for the use of GT for one of 12 final sampled residents (Residents 12) and one nonsampled resident (Resident 13). * The facility failed to ensure Resident 12's enteral feeding formula was labeled with the time as per the facility's P&P. * The facility failed to ensure RN 2 checked for gastric residual prior to the administration of the GT medication for Resident 13, as per the facility P&P. These failures posed the risk for complications related to the use of the GT for Residents 12 and 13.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the kitchen utensils were air dried prior to storage. * The facility failed to ensure the kitchen utensils were in good condition. * The facility failed to ensure the kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the foods prepared in the facility's kitchen.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control practices to prevent the development and transmission of diseases and infections. * RN 1 failed to disinfect the stethoscope after use on Resident 1 and prior to exiting the room. * RN 2 failed to disinfect the stethoscope after use on Resident 13 and prior to exiting the room. * CNA 1 failed to remove the gown and gloves and perform hand hygiene after touching Resident 1's surroundings and before touching Resident 10's environment. * Three linen cart covers were observed to be dirty, stained with black, white, and brown colors, and worn out. These failures had the potential to result in the transmission of infection to a vulnerable population of residents in the facility.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to administer the pneumococcal vaccines to two of five residents reviewed for vaccinations (final sampled residents, Residents 4 and 19). This failure had the potential to cause medical complications related to pneumococcal infections for the affected residents.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean, safe, and homelike environment for four of 12 final sampled residents (Residents 4, 8, 9, and 19) and one nonsampled resident (Resident 13). * There was a brownish colored stain on Resident 19's wall. * There were brown and white stains on Residents 8 and 13's curtains. * There was a brown feeding formula, GT tube cap and multiple gauze pads on the floor between Residents 4 and 8's beds. * There were feeding stains on Resident 8's IV pump and two other feeding pumps. * There was brownish colored droplet stains on the wall behind Resident 9's head of bed. Additionally, there was dry and brown colored residue on Resident 9's enteral feeding pump device and vacuum regulator. These failures had the potential to negatively impact the residents' safety and quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure the medications were stored properly. * There were two ounces of Zinc Oxide paste (medicated cream, ointment or paste that treats or prevents skin irritation like cuts, burns or diaper rash) at Resident 14's bedside table. This failure had the potential for visitors to have access to medications.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the medical records for two of 12 final sampled residents (Residents 12 and 19) were accurate. * The facility failed to ensure Resident 12's weekly wound assessment for 12/19/24 was recorded in the medical record. Additionally, the wound treatments administered to the resident did not match the Wound Consultant Physician's orders, and there was no documentation of the clarifications made on the physician's orders. * The facility failed to ensure Resident 19's skin assessment for measuring pressure sores and non-pressure sores was documented upon readmission and on a weekly basis. These failures had the potential for Residents 12 and 19's care needs not being met as their medical information was inaccurate.

Inspectors wroteBased on interview, medical record review and facility P&P review, the facility failed to take immediate action to prevent further potential abuse after the allegation of verbal and physical abuse was reported for one of two sampled residents (Resident 1). * The facility failed to immediately remove CNA 1 (alleged perpetrator) from the resident care assignment after the allegation of abuse was reported by Resident 1. The failure had the potential to negatively impact Resident 1's well- being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when an allegation of abuse involving CNA 1 and one of three sampled residents (Resident 1) was not reported timely to the CDPH, L&C Program. This failure posed the risk of potential abuse to go unreported and uninvestigated.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the proper infection prevention and control measure as evidenced by: * Lack of surveillance, tracking and mapping of suspected and confirmed infection cases. The summary of the monthly infection snapshot did not reflect the accuracy of the actual McGeer's tool for individual resident assessments. The facility did not include the residents who did not meet the McGeer's criteria in the discussion during the quarterly infection control meeting. * The facility failed to provide a system in place to protect the residents, staff, guests, and outside vendors free from possible exposure to infectious diseases by comingling the isolation and non-isolation residents' soiled laundry throughout the facility. These failures posed the increased risk for spread of infectious diseases.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure two of two ice machines were not clean and maintained as per the manufacturer's guidelines. This failure posed the risk of ice contamination and equipment to not function in the way it was intended.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the written information regarding the rights to accept or refuse the medical or surgical treatments and formulate the advance directive for one of 14 final sampled resident (Resident 19). In addition, the facility did not have a written policy on advance directives. These failures had the potential for the residents' decision regarding the resident's healthcare and treatment options not being honored.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the plans of care for two of 14 final sampled residents (Resident 6 and 10) were developed, resident centered, and with measurable goals. This failure posed the risk of not providing appropriate, individualized care to Residents 6 and 10.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the comprehensive plans of care for two of 14 final sampled residents (Residents 7 and 10) were revised to reflect the residents' current care needs and interventions. * The facility failed to revise the comprehensive plan of care for Resident 7's use of the bilateral knee braces. * The facility failed to revise the comprehensive plan of care for Resident 10's use of PICC line. These failures posed the risk of not providing the residents with individualized and person-centered care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent and worsening of pressure injuries for one of 14 final sampled residents (Resident 13). * The facility failed to ensure the licensed staff were trained and followed the manufacturer's guidelines on the LAL mattress settings. * The facility failed to ensure Resident 13 was repositioned every two hours per the physician's order. These failures put Resident 13's pressure injuries to reoccur and not heal.

Inspectors wroteBased on observation, medical record review, and interview, the facility failed to ensure the treatment was provided to one of 14 final sampled residents (Resident 7) to prevent a decline in the ROM functions. * The facility failed to follow a physician's order to apply a knee brace to Resident 7's both knees. This failure had the potential for Resident 7 to sustain a decline in ROM functions, leading to muscle atrophy and decrease in functioning.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for one of the 14 final sampled residents (Resident 22). * The facility failed to ensure Resident 22's bed alarm was on. This failure had the potential for the resident to sustain another fall.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to follow the physician's order for the indwelling urinary catheter (a tube placed in the body to drain and collect urine from) maintenance for one of 14 final sampled residents (Resident 13). This failure had the potential for not providing the necessary care and services to prevent adverse complications of obstruction or infections for residents with an indwelling urinary catheter.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the physician's orders were clarified for one of 14 final sampled residents (Resident 13) for head of bed (HOB) elevation for aspiration precautions when the resident received a feeding tube. This failure had the potential to cause the resident to experience adverse reactions from GT feeding

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the intravenous accesses for one of 14 final sampled residents (Resident 10). In addition, the facility failed to ensure the PICC line external catheter and arm circumference measurements were performed and documented in the medical record for Residents 10. These failures had the potential to delay the identification of catheter related complications for the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the completion of side rails assessments for two of 14 final sample residents (Residents 6 and 8). * Resident 6 did not have two quarterly entrapment assessments completed. * Resident 8's assessments for bed side rails use were not completed. These failures posed the risk for the residents' safety associated with bedrails usage.

Inspectors wroteBased on interview, medical record review, and facility P&P, the facility failed to ensure the pharmaceutical services were provided to meet the residents' needs for two of 14 final sampled residents (Residents 6 and 16). * The nursing staff failed to ensure the physician's order not to crush paroxetine (antidepressant medication) tablet was clarified with the pharmacist or physician to obtain an alternate form of medication to administer via GT for Resident 16. * The medications ordered to administer with meals were administered when the GT feeding was not on for Resident 6. These failures had the potential to cause the adverse reactions due to improper medication administration to the residents.

Inspectors wroteBased on observation, interview, medical record review, and facility's P&P review, the facility failed to ensure the necessary care and services were provided to prevent adverse reactions of a medication for experiencing active bleeding from multiple sources while receiving enoxaparin (a medication used to thin the blood) for one of 14 final sampled residents (Resident 13). This failure had the potential to result in Resident 13 to have more or active bleeding in his urine, and bleeding from his tracheostomy tubing (a tube inserted into the windpipe in front of the neck to assist in breathing).

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of 14 final sampled residents (Resident 19) was free from the unnecessary psychotropic medications (medication that affects the brain activity). * The facility failed to provide non-pharmacological interventions to Resident 's 19's crying and constantly crying episodes due to depression and severe anxiety. * The facility failed to ensure a GDR was attempted for Resident 19's buspirone (medication to treat anxiety) and escitalopram (medication to treat depression) use. These failures had the potential for the physician to not have the necessary information and the residents to receive the unnecessary medications.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the medications were stored and labeled properly and failed to discard the expired supplies. * Medication Cart A had one open and unlabeled Lantus pen (an insulin medication to treat high blood sugar), and three expired supplies. * The facility failed to monitor the temperature of Medication room [ROOM NUMBER]. * Medication Cart B had two expired supplies. These failures posed the risk for negatively affect the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary adaptive equipment was provided for one of 14 final sampled residents (Resident 10). * Resident 10 was not provided with a plate guard, non-slip table mat, and a suction cup as per the physician's order. This failure had the potential for Resident 10 not having an appropriate assistive device to consume her food and drinks.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen when: * The facility's P&P for dating foods was not followed. * The staff was not performing handwashing between soiled and clean tasks. * The food preparation equipment was not clean when stored. * The food preparation equipment was not air dried. * A handwashing sink was used for purposes other than handwashing. These failures posed the risk to cause food borne illnesses in a highly susceptible resident population of three residents who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview and facility P&P review, the facility failed to ensure the facility staff responsible for handling food brought for residents from the outside and visitors who brought food for residents from the outside were educated on safe food handling procedures. These failures posed the risk for food borne illness for residents who consume food from the outside.

Inspectors wroteBased on observation, interview, medical record review, facility document interview, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate and complete including the measurements during the bed inspection when identifying areas of possible entrapment with the use of bed side rails for four of 14 final sampled residents (Residents 5, 7, 8, and 16). These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on observation and interview, the facility failed to ensure one of the 14 final sampled residents (Resident 1) was treated with dignity while receiving medications. * RN 2 failed to close Resident 1's privacy curtains while giving the medications via GT. This failure had the potential to negatively affect Resident 1's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the MDS was accurate for one of 14 final sampled residents (Resident 6). This failure posed the risk of Resident 6 to not have an individualized plan of case based on her specific needs.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the refuse was stored in a sanitary manner. This failure had the potential for pest contamination.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pneumococcal vaccine annually and as needed to one of 14 final sampled residents (Resident 6). This posed the risks of contracting serious illness associated with pneumococcal bacteria.